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Waste Tire Sup vey & Inspection ReporAnspection Report Number ■ <br /> CalRecycle CalStte of Recyclellfornia 181(Rev.10/10) 1 1 - 1242413 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Il l V l Routine Q Observation Suffix: <br /> Local C If Referral,choose referral type(Fill one) <br /> Identifier. �Gl�'1. �� L E V , Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physlca ddreffss <br /> �� <br /> jJ��I 7 I'GLG I <br /> Inspection Date - 0 <br /> Time In Time Out <br /> Business Rep Title ® AM 10 AM <br /> 1 - ' L G 0 PM l j d v 0 PM <br /> gyp{ <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> hl (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> v <br /> ® Active ® Passenger ® Generator Q Outdoor <br /> GPS Latitude 0 Closed Q Altered <br /> Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use ® Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> (1) Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or Ex7) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Q1 Other:§ <br /> z <br /> Comments <br /> /fes{J <br /> 1 <br /> Inspection Form Included: Q <br /> Comments Included: <br /> B ess Rep's Signat 4 Phone Number I. e is ature Phone Number <br /> INSTRUCTIONS ON BACK ** Incorrect: E X M L 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop L © ■ <br />